Lifestyle Index Name First Last PhoneEmail This survey is meant to help your doctor understand what you’re experiencing on a regular basis — whether it’s caused by your eyes, posture, stress, etc. Your responses will help make sure you receive the best care possible.HeadachesYou get headaches of any severity each week (even just a dull ache counts). Never Rarely Sometimes Very Often Always Your headaches tend to get worse later in the day. Never Rarely Sometimes Very Often Always Your headaches are generally worse at work than they are at home or on weekends. Never Rarely Sometimes Very Often Always Stiffness / pain in neck / shouldersYour neck gets stiff and sore when you work at a computer or read (This might even be from your posture). Never Rarely Sometimes Very Often Always You experience frequent tension in your head, neck or shoulders. Never Rarely Sometimes Very Often Always You get frequent massages/chiropractic adjustments. Never Rarely Sometimes Very Often Always Discomfort with Computer UseYou feel like you are more productive at work in the morning vs. the afternoon. Never Rarely Sometimes Very Often Always Your eyes get tired, burn, or get red easily when you work at a computer for long hours. Never Rarely Sometimes Very Often Always Tired EyesYour eyes feel fatigued/tired at the end of a workday. Never Rarely Sometimes Very Often Always Your eyes generally feel better in the morning compared to the end of the day. Never Rarely Sometimes Very Often Always Dry Eye SensationYour eyes and/or contacts tend to dry out when you are working at a computer or reading. Never Rarely Sometimes Very Often Always Your eyes progressively feel more dry/sandy/gritty as the day goes on. Never Rarely Sometimes Very Often Always Light SensitivityDriving at night is difficult because of glare from highlights. Never Rarely Sometimes Very Often Always Fluorescent lights bother you in large spaces (grocery store, department store, etc.). Never Rarely Sometimes Very Often Always DizzinessRiding in a car gives you motion sickness. Never Rarely Sometimes Very Often Always You sometimes feel a sensation of vertigo or disconnectedness from your environment. Never Rarely Sometimes Very Often Always Additional NotesAny additional notes about these symptoms: Your Score
